Quote Request for Agents

Agent's Information:

Agent Name:        Telephone Number:

Agent E-mail Address:

Client's Information:

Client Name:      Spouse's Name:

Client DOB:       Spouse's DOB:

State of Residence: Select AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

                                                                                                      Client                          Spouse
Please check the box if the answer is yes.

Has your client/clients had, currently have,
have ever been medically
diagnosed as having or have
been treated for:                                                                                                         
(Please check any that apply)
Stroke, Amyotrophic Lateral Sclerosis,
Multiple Transient Ischemic Attacks,
TIA within 5 years, Alzheimer's Disease
Dementia, Mental Retardation,
Schizophrenia, Muscular Dystrophy,
Multiple Sclerosis, Parkinson's Disease,
Diabetes with complications, Cancer that has
spread to another area of your body or that
has been treated in the last 2 years, or
Organ transplant?                                                                                                             

Has your client/clients ever been treated for or medically
diagnosed as having AIDS, ARC, or have ever
tested positive for the HIV infection?                                                                             

Do they currently reside in, or have they
been advised to enter, or are they
planning to enter a nursing home, assisted
living facility or residential care facility or
are they currently receiving home health care
services or attending adult day care?                                                                            

Do they require human help or supervision
for any of the following?                                                                                                    
(Please check any that apply)
bathing, dressing, eating, walking, toileting,
transferring from bed to chair or bladder
control.

Do they currently use any of the following?                                                                     
(Please check any that apply)
dialysis, oxygen, wheelchair, walker, quad
cane, or crutches.

Height / Weight                                                                          /              /

                 
Are either of them currently taking any medications? Yes No

Client : Medication(s), Dosage, & Condition

Spouse: Medication(s), Dosage, & Condition

Carrier/Product Information:       No more than 2 companies and/or products

Quote 1: Select Allianz Generation Pro II Genworth Privileged Choice Genworth Classic Select John Hancock Custom Care John Hancock Leading Edge John Hancock FamilyCare MetLife Value MetLife Ideal MetLife Premier MetLife Facility Only MedAmerica Simplicity Penn Treaty Personal Freedom Penn Treaty Secured Risk              Quote 2: Select Allianz Generation Pro II Genworth Privileged Choice Genworth Classic Select John Hancock Custom Care John Hancock Leading Edge John Hancock FamilyCare MetLife Value MetLife Ideal MetLife Premier MetLife Facility Only MedAmerica Simplicity Penn Treaty Personal Freedom Penn Treaty Secured Risk

Benefit Information:

Daily Benefit ($50 - $300):    or Monthly ($1500 - $9000):

Benefit Period: Select 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 10 Year Lifetime/Unlimited              Elimination Period: Select 30 90 180 365

Inflation Option: Select Simple Compound GPO                Additional Riders: Select Waiver of EP for HHC Shared Rider Restoration of Benefits Return of Premium Survivorship Non-Forfeiture

Are we in competition with another carrier? Yes No

If yes, who?

When is your meeting with the client? Select 1-2 days 2-4 days 4-6 days 7+ days